Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Wednesday, May 11, 2005

Incorrections

You may have seen the PBS documentary last night on mentally ill people in prison. This is an important subject, but it isn't exactly news. Some 12 years ago I had the opportunity to visit the maximum security institution in Walpole, Massachusetts with Judge Albert Kramer, who was Presiding Judge of the Quincy District Court (now retired). We toured a cellblock and then we met with a group of lifers. Actually they weren't all doing life, but they all had sentences of 20 years or more.

One of the guys said (warning: Janet Malcolm quotes), "I've been in and out all my life. I started out in DYS when I was 16, and you keep seeing the same people. You know, we're criminals. But now, I see all these guys in here who ought to be in the fucking Pine Street Inn. It's ridiculous." (The Pine Street Inn is a big homeless shelter in Boston. Note that these guys did not claim to be innocent. They said they understood why they were in prison, but they also made a plea to us that they were human beings, whose lives were degraded. What actually goes on in prison is for another time, however.)

Al Kramer said there were two factors at work. First, the legislature had taken up the progressive cause of deinstitutionalization of the mentally ill in the 1970s and '80s, and they had largely emptied the mental hospitals. The idea was to provide intensive community supports, including staffed group homes and integrated mental health and medical care. But after they got done saving hundreds of millions by closing the snake pits, they never got around to spending the money on community based alternatives. So we ended up with people with severe mental illnesses sleeping in cardboard boxes and, of course, commiting crimes out of desperation or delusion.

Second, the public wanted to get tough on crime and they were tired of all those bleeding heart liberal judges coddling criminals, so the legislature passed determinate sentencing laws. Judges no longer had discretion, and Al had to send people to prison whether it made any sense or not.

As regular readers know, I'm not inclined to give GW Bush a whole lot of credit, but he did appoint a presidential commission to study mental health issues in the U.S. (Hey, that's almost as good as actually doing something about a problem, isn't it?) The President's New Freedom [sic] Commission on Mental Health tells us:

[A]bout 7% of all incarcerated people have a current serious mental illness. The proportion with a less serious form of mental illness is substantially higher. People with serious mental illness who come into contact with the criminal justice system are often poor, uninsured, disproportionately members of minority groups, homelss, and living with co-occurring substance abuse and mental health disorders. They are likely to continually recycle through the mental health, substance abuse, and criminal justice systems. When they are put in jail, people with mental illnesses frequently do not receive appropriate mental health services. Many lose their eligibility for income supports and health insurance benefits that they need to re-enter and re-integrate into the community after they are discharged.

So, what do they do? They end up on the streets, disabled and insane. They may start screaming at an invisible interlocutor or taking their clothes off in the middle of Columbus Ave., whereupon the cops will take them to a state mental institution where they will be medicated. After a week or two, they'll be calmed down on the meds, and they'll be discharged -- to the Pine Street Inn. Then they'll destabilize again, shoplift or trespass or perhaps assault someone, and this time the cops will take them to the lockup and book them, and they'll wind up back in jail. By this time they're three or four or five time losers, probably parole violators, and they'll get a long sentence.

And so it goes. I propose that this is completely nuts. In other words, we are all insane.